A maternal death is defined as the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the duration and site of
the pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes. - World Health
Organization.

In 2000, the UN estimated global maternal mortality at 529,000, of which less
than 1% occurred in the developed world. Most of these deaths have been
preventable for decades, because treatments to avoid such deaths have been well
known since the 1950s.

According to the CDC, maternal mortality in the USA fell as in the following
graph:

UK Figures

Generally there is a distinction between a direct maternal death that is the
result of a complication of the pregnancy, delivery, or their management, and an
indirect maternal death that is a pregnancy-related death in a patient with a
pre-existing or newly developed health problem. Other fatalities during but
unrelated to a pregnancy are termed accidental, incidental, or non-obstetrical
maternal deaths.

The major causes of maternal death are:-

bacterial infection,

variants of gestational hypertension including pre-eclampsia and HELLP
syndrome,

obstetrical hemorrhage,

ectopic pregnancy,

puerperal sepsis,

amniotic fluid embolism,

and complications of unsafe or unsanitary abortions.

Lesser known causes of maternal death include:-

renal failure,

cardiac failure, and

hyperemesis gravidarum.

Over 90% of maternal deaths occur in developing countries.

Maternal Mortality Ratio is the ratio of the number of maternal deaths
per 100,000 live births.

The MMR is used as a measure of the quality of a health care system.

Sierra Leone has the highest maternal death rate at 2,000, and Afghanistan
has the second highest maternal death rate at 1900 maternal deaths per 100,000
live births, reported by the UN based on 2000 figures.

According to the Central Asia Health Review, Afghanistan's maternal mortality
rate was 1,600 in 2007.[7]

Lowest rates included Iceland at 0 per 100,000 and Austria at 4 per 100,000.

In the United States, the maternal death rate was 11 maternal deaths per
100,000 live births in 2005.[8]

In sub-Saharan Africa the lifetime risk of maternal death is 1 in 16, for
developed nations only 1 in 2,800.

In 2003, the WHO, UNICEF and UNFPA produced a report with statistics gathered
from 2000.

The world average per 100,000 was 400, the average for developed regions was
20.

United Kingdom

In the UK, maternal mortality rates can be calculated in two ways:

1. Through official death certification to the Registrars General (the Office
for National Statistics and its equivalents).2. Through deaths reported to the Confidential Enquiry into Maternal and Child
Health (CEMACH).2 A report is produced every 3 years.

The overall maternal death rate for the Enquiry is calculated from the number
of deaths assessed as being due to Direct and Indirect deaths.

Direct deaths are defined as those related to obstetric complications
during pregnancy, labour or puerperium (6 weeks) or resulting from any
treatment received.

Indirect deaths are those associated with a disorder the effect of which is
exacerbated by pregnancy.

Late deaths occur ≥ 42 days after end of pregnancy.

Most maternal mortality occurs in developing world with >500,000/year.4,5
Risk factors for maternal deaths in the UK include:

Social disadvantage:Women living in families where both partners were unemployed, where social
exclusion was an associated problem, were up to 20 times more likely to die
than women from the more advantaged groups. In addition, single mothers were
three times more likely to die than those in stable relationships.

Poor communities:Women living in the most deprived areas had a 45% higher death rate than
women living in the most affluent areas.

Minority ethnic groups:Women from ethnic groups were, on average, three times more likely to die
than caucasian women. Black African women, including asylum seekers and
newly arrived refugees had a mortality rate seven times higher than
caucasian women. These groups were shown to have had major problems in
obtaining obstetric care. This disparity in mortality rates between ethnic
groups has been noted in other affluent societies.6

Late booking or poor attendance:20% of the women who died from Direct or Indirect causes booked for
maternity care after 22 weeks of gestation, or had missed over four routine
antenatal visits.

Delayed pregnancy:In 2003-05 the increase in the numbers and proportion of maternities which
were to women aged 35 and over continued.

Obesity:There is an increasing trend for greater BMI.

Domestic violence:14% of all the women who died declared that they were subject to violence in
the home.

Substance abuse:8% of all the women who died were substance misusers.

Suboptimal clinical care:67% of the women who died were considered to have some form of suboptimal
clinical care.

Lack of inter-professional and/or inter-agency communications:There were many cases where the care provided to the women who died was
hampered by a lack of cross-disciplinary working. In several cases crucial
clinical information, which may have affected the outcome, was not passed
from the GP to the midwifery or obstetric services, or shared between
consultants in other specialities.

Management

It is the responsibility of the GP or community midwife to notify the local
Director of Public Heath.

If death occurs in hospital a co-ordinator, usually a midwife, should be
appointed.They should perform the following and keep a complete record of all actions:

Ensure relatives have a suitable member of staff as a single contact
point.

Consultant on-call should see relatives as soon as possible and woman's
own consultant told of death as soon as next in hospital.

Supervisor of midwives is informed.

Mortuary and pathologist on duty informed.

Try to obtain permission from next-of-kin for post-mortem examination to
confirm cause of death (coroner may direct one performed if any doubt). N.B.
If there a dead fetus in utero, there is no legal requirement for a death
certificate but one can often be supplied if wished.

Ask relatives if they would like to see a culturally appropriate religious
adviser.

All relevant documents are sent to the coroner.

Consider offering support to staff involved.

Maternal death rates in the 20th century

The death rate for women giving birth has fallen dramatically in the 20th
century.

The historical level of maternal deaths is probably around 1 in 100 births.

This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the
patient information and medical advice provided.